The Use of a Pediatric Abdominal Trauma Protocol Improves Resource - - PowerPoint PPT Presentation

▶
the use of a pediatric abdominal trauma protocol improves
SMART_READER_LITE
LIVE PREVIEW

The Use of a Pediatric Abdominal Trauma Protocol Improves Resource - - PowerPoint PPT Presentation

Sep 15, 2022 467 likes •731 views

The Use of a Pediatric Abdominal Trauma Protocol Improves Resource Utilization Bindi Naik-Mathuria MD, Sara Fallon MD, Fariha Sheikh MD, Mary Frost RN, Daniel Christopher RN, David Delemos MD Divisions of Pediatric Surgery and Pediatric

slide-1
SLIDE 1

The Use of a Pediatric Abdominal Trauma Protocol Improves Resource Utilization

Bindi Naik-Mathuria MD, Sara Fallon MD, Fariha Sheikh MD, Mary Frost RN, Daniel Christopher RN, David Delemos MD

Divisions of Pediatric Surgery and Pediatric Emergency Medicine Trauma Services, Texas Children’s Hospital Baylor College of Medicine, Houston, TX

slide-2
SLIDE 2

Page 1 xxx00.#####.ppt 11/18/2014 11:00:18 AM

Surgical Services Trauma Services

Background

  • After failure to control the airway, blunt abdominal

trauma (BAT) is the second most frequent cause of preventable death in pediatric trauma patients

  • Evaluation of pediatric BAT can be challenging
  • External signs may be few
  • Physical examination can be unreliable
  • CT is over-utilized and poses radiation risk
slide-3
SLIDE 3

Page 2 xxx00.#####.ppt 11/18/2014 11:00:19 AM

Surgical Services

Background

  • Young level I trauma center

(certified in 2010)

  • Large institution: multiple EM

and Surgery providers leads to variability in evaluation/management

  • New protocol in Aug 2011 –

primary evaluation level 2 activations by EM staff; trauma surgeon consulted

  • nly when necessary

Trauma Services

slide-4
SLIDE 4

Page 3 xxx00.#####.ppt 11/18/2014 11:00:20 AM

Surgical Services Trauma Services

Objectives

  • QI project: Development of an evidence-based

protocol to evaluate abdominal trauma in EC

  • To standardize care among multiple providers
  • To ensure appropriate and timely surgery consultation
  • To decrease unnecessary CT and lab use in evaluation of

abdominal trauma

  • To maintain or improve safety and quality of care of

trauma patients

slide-5
SLIDE 5

Unconscious child (GCS <=8), significant mechanism

(ex. High speed MVC, fall >10 ft, suspected NAT)

Call Surgery STAT if not already present Hemodynamically STABLE FAST if available Hemodynamically UNSTABLE OR if clinical or FAST evidence of abdominal bleeding Look for other sources

  • f hypotension,

fluid resuscitation Admit to Trauma Service in PICU CT abd/pel w/ IV contrast Admit to Trauma for OR vs. Non-

  • perative mgmt

ABDOMINAL TRAUMA PROTOCOL BLUNT TRAUMA - UNCONSCIOUS

slide-6
SLIDE 6

ABDOMINAL TRAUMA PROTOCOL BLUNT TRAUMA- CONSCIOUS, RELIABLE EXAM

Abdominal tenderness or distention OR if clinical or FAST evidence of abdominal bleeding Admit to Trauma for OR vs. Non-operative mgmt

CONSULT SURGERY

FAST if available CT abd/pel w/ IV contrast (per surgery discretion) Observe in EC, OK to discharge if pain-free, tolerating PO and no additional injuries needing admission Hemodynamically UNSTABLE Hemodynamically STABLE Conscious child (GCS 14-15), significant mechanism (ex. High speed MVC, fall >10 ft, suspected NAT) Reliable abdominal examination

slide-7
SLIDE 7

ABDOMINAL TRAUMA PROTOCOL BLUNT TRAUMA- CONSCIOUS, UNRELIABLE EXAM

Conscious child, significant mechanism (ex. High speed MVC, fall >10 ft, suspected NAT) Unreliable or equivocal abdominal examination (ex. GCS 9-13 or distracting injury) LABS: AST/ALT, CBC, Amy/Lip, UA w micro OR if clinical or FAST evidence of intraabdominal bleeding Admit to Trauma for OR vs. observation

CONSULT SURGERY

Hemodynamically UNSTABLE Hemodynamically STABLE FAST if available CT abd/pel w/ IV contrast (per surgery discretion) Discharge (only if GCS 15) vs. admit to trauma service for

  • bs for pain or anxiety control

FAST if available Repeat abd exam

ALT/AST > 100, Hgb <10 or Hct <30%, Amy/Lip elevated, UA >50 RBC/HPF

slide-8
SLIDE 8

ABDOMINAL TRAUMA PROTOCOL BLUNT TRAUMA- ABDOMINAL WALL BRUISING

Seatbelt Sign or other abdominal wall bruising (ex. Handlebar injury)

2-view lumbar spine before moving patient to r/o fracture

OR if clinical or FAST evidence of abdominal bleeding or bowel injury Admit to Trauma for OR vs. observation Hemodynamically UNSTABLE and/or signs of peritonitis Hemodynamically STABLE FAST if available CT abd/pel w/ IV contrast

Log roll, for exam , maintain on board until spine imaging completed

CONSULT SURGERY

Don’t need additional spinal CT

slide-9
SLIDE 9

Page 8 xxx00.#####.ppt 11/18/2014 11:00:21 AM

Surgical Services

Methods

  • Protocol implementation
  • Prospective, longitudinal

study

  • Comparison of outcomes

Pre/Post Protocol (POST 1)

  • Protocol revision based on

review of outcomes

  • Comparison of outcomes

following revision (POST 2)

Trauma Services

slide-10
SLIDE 10

Page 9 xxx00.#####.ppt 11/18/2014 11:00:22 AM

Surgical Services Trauma Services

2011 2012 2013 2014

JAN DEC

Pre-Protocol (n = 117)

JAN AUG

Post-Protocol v1 (n = 148)

SEPT MAR

Post-Protocol v2 (n = 56)

SEPT

P1 P2

slide-11
SLIDE 11

Page 10 xxx00.#####.ppt 11/18/2014 11:00:22 AM

Surgical Services Trauma Services

Methods

  • Study population:
  • Patients who presented to EC with mechanism for

abdominal trauma who received CT at our institution

  • Exclusion criteria:
  • Neonates
  • Prior abdominal imaging at another facility
  • Suspected non-accidental trauma
  • Remote injuries (> 24 hours)
  • Significant congenital anomalies
slide-12
SLIDE 12

Page 11 xxx00.#####.ppt 11/18/2014 11:00:23 AM

Surgical Services

Pre (n=117) Post 1 (n=148) Post 2 (n=56) P-value Male gender 61% 63% 55% 0.62 Admission rate 73% 83% 82% 0.24 Mean age at admission (SD) 8.4 (5.2) 9.1 (4.8) 7.8 (5.3) 0.21 Median ISS (Range 0-75) 5 6 9 0.11 Median Hosp LOS (Range 1-57 days) 1.5 2 3 0.05 Survival (%) 98% 100% 98% 0.27

Trauma Services

slide-13
SLIDE 13

Page 12 xxx00.#####.ppt 11/18/2014 11:00:24 AM

Surgical Services

Mechanism of Injury

Mechanism Pre Post 1 Post 2 MVA 30% 22% 36% Auto-ped 22% 27% 22% Fall 21% 19% 16% Blunt object 13% 13% 13% ATV/Bike 6% 14% 6% Sports 6% 3% 7%

Trauma Services

slide-14
SLIDE 14

Page 13 xxx00.#####.ppt 11/18/2014 11:00:25 AM

Surgical Services Trauma Services

POST 1 Results: Before and After

23% 24% 33% 13% 19% 24%

0% 5% 10% 15% 20% 25% 30% 35%

Jan 2011- Aug 2011 Sept 2011- Dec 2011 Jan 2012- Dec 2012 % Positive Scans % Clinically Significant Scans Pre-Protocol Transition Post-Protocol v1

slide-15
SLIDE 15

Page 14 xxx00.#####.ppt 11/18/2014 11:00:26 AM

Surgical Services Trauma Services

Protocol Deviation

  • Some step of the protocol was not followed 30% of the
  • time. Most common:
  • CT based on mechanism alone
  • CT before surgeon evaluation most common
  • 46 CT scans (36%) may have been avoided if protocol

had been followed

  • Clinically significant CT scans when protocol followed =

43% vs. 11% when not followed (p = 0.001)

slide-16
SLIDE 16

Page 15 xxx00.#####.ppt 11/18/2014 11:00:26 AM

Surgical Services Trauma Services

POST 1 Laboratory Use

  • The cost of ER laboratory tests ordered for these patients did

not change after protocol implementation (mean $254 vs. $269 per patient, p=0.50)

10 20 30 40 50 60 70 80 90 100 CBC Amy/Lip LFTs UA w micro Chem 10 T+S PT/PTT Chem 7 AST/ALT H/H BUN/Cr

slide-17
SLIDE 17

Unconscious child (GCS <=8), significant mechanism for abdominal trauma Hemodynamically Stable Call Surgery STAT if not already present Admit to Trauma Service in PICU CT abd/pel w/ IV contrast Admit to Trauma for OR vs. non-operative management No initial Abdominal labs needed

BLUNT TRAUMA - UNCONSCIOUS

slide-18
SLIDE 18

Abdominal tenderness? Admit to Trauma for OR vs. Non-

  • perative mgmt

CONSULT SURGERY CT abd/pel w/ IV contrast (per surgery discretion) OK to discharge if pain-free, tolerating PO and no additional injuries needing admission

Conscious child, GCS 14-15, significant mechanism

(ex. High speed MVC, fall >10 ft, suspected NAT)

Reliable Abdominal Examination and Hemodynamically Stable NO Abdominal labs needed Obtain Stable AT lab panel TENDER NON-TENDER

CONSCIOUS, RELIABLE EXAM

slide-19
SLIDE 19

CONSCIOUS, UNRELIABLE EXAM

Conscious child, significant mechanism for abdominal trauma Unreliable or equivocal abdominal examination

(ex.Young age, distracting injury, GCS 9-13),

Hemodynamically Stable Admit to Trauma for OR vs. observation CONSULT SURGERY CT abd/pel w/ IV contrast (per surgery discretion) OK to discharge if tolerating po and no other injuries requiring admission Repeat abdominal exam if reliable and GCS 15. If unreliable, consider evidence for head injury

ALT/AST > 100, Hb <10

  • r Hct <30%, Amy/Lip >

100, UA >50 RBC/HPF

TENDER NON-TENDER Obtain Stable AT lab panel

slide-20
SLIDE 20

ABDOMINAL WALL BRUISING

Seatbelt Sign or other abdominal wall bruising

(ex. Handlebar injury), Hemodynamically Stable Admit all patients to Trauma for OR

  • vs. observation

CT abd/pelvis w/ IV contrast* (per surgery discretion)

CONSULT SURGERY

* CT A/P with reconstruction is enough to evaluate spine – additional spinal CT is NOT necessary

Obtain Stable AT lab panel

Maintain strict spinal precautions for seatbelt sign until imaging complete – if no CT, then obtain T/L spine x rays

slide-21
SLIDE 21

Page 20 xxx00.#####.ppt 11/18/2014 11:00:28 AM

Surgical Services

Abdominal Trauma Lab Panel Hemodynamically Stable H/H Amylase/Lipase AST/ALT UA w/ micro UPT for teen female Abdominal Trauma Lab Panel Hemodynamically Unstable H/H Amylase/Lipase AST/ALT UA w/ micro UPT for teen female PT/PTT T+S BUN/Cr

Trauma Services

slide-22
SLIDE 22

Page 21 xxx00.#####.ppt 11/18/2014 11:00:28 AM

Surgical Services Trauma Services

POST 2 Results: Improved CT Utilization

23% 32% 49% 14% 21% 32% 0% 10% 20% 30% 40% 50% 60%

% Positive Scans % Clinically Significant Scans p=0.003 p=0.03

Pre-Protocol Protocol v1 Protocol v2 N=117 N=148 N=56 * ** ** *

slide-23
SLIDE 23

Page 22 xxx00.#####.ppt 11/18/2014 11:00:29 AM

Surgical Services Trauma Services

Balance Measures

0.00 50.00 100.00 150.00 200.00 250.00 300.00 350.00 Jan 2011- Dec 2011 Jan 2012- Aug 2013 Sept 2013- Mar 2014

Time (mins)

Time to CT scan and ER Length of Stay

  • Avg. ER Stay
  • Avg. Time to

CT Scan

Pre-Protocol Protocol v1 Protocol v2 There were no missed injuries during these time periods

slide-24
SLIDE 24

Page 23 xxx00.#####.ppt 11/18/2014 11:00:30 AM

Surgical Services Trauma Services

Laboratory Cost Analysis

Pre (n-117) Post 1 (n=148) Post 2 (n=56) P value Mean total cost

  • f labs (SD)

244 (149) 273 (137) 202 (140) 0.006 Component CBC (%) 4% 19% 63% < 0.001 Component Chemistry (%) 6% 0% 54% < 0.001 Component LFTs (%) 21% 31% 74% < 0.001

slide-25
SLIDE 25

Page 24 xxx00.#####.ppt 11/18/2014 11:00:31 AM

Surgical Services Trauma Services

Conclusion

  • An institutional protocol to streamline evaluation of

children with suspected blunt abdominal trauma was effective in decreasing unnecessary CT use and laboratory costs

  • Future directions include further protocol refinement

to decrease the role of CT in the evaluation algorithm

slide-26
SLIDE 26

Page 25 xxx00.#####.ppt 11/18/2014 11:00:32 AM

Surgical Services Trauma Services Trauma Services

Thank You!